Provider Demographics
NPI:1104879568
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PENN-TIMITY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-204-9718
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:FINCASTLE
Mailing Address - State:VA
Mailing Address - Zip Code:24090-0220
Mailing Address - Country:US
Mailing Address - Phone:540-473-8240
Mailing Address - Fax:540-473-8242
Practice Address - Street 1:21 ACADEMY STREET
Practice Address - Street 2:
Practice Address - City:FINCASTLE
Practice Address - State:VA
Practice Address - Zip Code:24090-0220
Practice Address - Country:US
Practice Address - Phone:540-473-8240
Practice Address - Fax:540-473-8242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4975324Medicaid
600000045Medicare PIN